Tailored therapy for bradyarrhythmias: integrating leadless pacing, conduction system pacing, and cardioneuroablation

Bradyarrhythmias represent a heterogeneous group of disorders ranging from intrinsic cardiac disease to functional autonomic disturbances. Although conventional transvenous pacing remains the cornerstone of treatment, a uniform device-based approach may not adequately address the diverse pathophysiological substrates underlying bradyarrhythmias. Device-related complications, pacing-induced ventricular dysfunction, and the growing recognition of vagally mediated bradyarrhythmias have highlighted the need for a more individualized therapeutic strategy. Recent advances have expanded the available treatment options through the development of leadless pacing, conduction system pacing (CSP), and cardioneuroablation (CNA). Importantly, these therapies should not be viewed as interchangeable alternatives, but rather as complementary approaches targeting distinct clinical scenarios. Leadless pacing minimizes transvenous hardware and may be particularly advantageous in patients at increased risk of device-related complications, limited venous access, or low anticipated pacing requirements. CSP preserves physiological ventricular activation and may reduce the risk of pacing-induced cardiomyopathy in patients with a high expected ventricular pacing burden or a vulnerable ventricular substrate. Conversely, CNA provides a mechanism-based, device-free therapeutic option for carefully selected patients with functional, vagally mediated bradyarrhythmias. In this review, we propose a practical framework for patient selection based on three complementary phenotypes: the high-risk and low-pacing-burden patient, the high-pacing-burden and vulnerable ventricle, and the vagal phenotype (see Central Illustration). By integrating pathophysiology, anticipated pacing burden, ventricular susceptibility, and autonomic substrate, contemporary management can move beyond the traditional device-centered paradigm toward a tailored approach aimed at delivering the right therapy to the right patient.